REP PORTAL

Physician Trial Form

Distributor Information

Evaluation Period

Payment Information

Two (2) C Scope kits and capital for demo will be sent for the purpose of evaluation. The tablet and handpiece must be returned after the evaluation period has ended. If the capital is not returned, the card listed above will be charged for the value of the equipment, $5,900. The trial procedure will be performed with a demo C Scope tablet that does not automatically prevent scope reuse. I acknowledge that the C Scope kit is single use and will be discarded once the procedure is completed.

Physician Signature

Rep Signature

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ZSC-200-08-08-20 Rev. 02